Evidence based medicine and doulas: why we need to look at what we know and how we know it
We expect health professionals to act on the latest and best information and not use their professional power, gender or past experience to put pressure on women to choose one intervention over another, we expect them to tell us the risks and benefits of a choice in a dispassionate manner, using the best available evidence, but we do we do the same?
One of the on-going issues in the doula community is that of the giving of information (and not advice of course…) how do we decide what is appropriate to give? Should doulas know more about how to assess the quality of information?
I often see doulas suggesting that women might decline tests or treatment (from Group B Strep and gestational diabetes to declining post dates induction) whilst most are probably just trying to make sure that women know they have options and are able to decline anything they want to, sometimes it may come across as advice, as described by the woman in this blog post, who feels her doulas reassurance contributed to her babies difficulties after birth:
The Doula UK philosophy states:
“Doulas do not give any medical advice but they should have a good understanding of the physiology of birth and the postnatal period so can provide support to help the woman find solutions when she needs guidance. This distinction between advice and support is important”
And DUK guidelines on social media remind us:
“You are free, of course, to express your own personal opinions but we ask that you exercise the same good judgment, discretion, taste and common sense when communicating through social media as you do when carrying out any official doula activity. “
We are rightly reminded to think about confidentiality and professional relationships, but our interaction on the many support and advocacy groups are also relevant, many doulas use the word doula in their personal facebook accounts, so their personal opinions reflect on the doula community, and even if we don’t self identify our personal accounts as ‘doula’ we are usually still known as such, if we make a personal opinion or suggestion, can that be considered advice?
In an online situation we feel removed from the actual situation, but we need to remember these are real women and babies when we suggest they don’t tell care providers when their waters break or to use homeopathy instead of conventional treatments.
In trying to protect clients from harm, are we tempted to downplay the risk based on our experience and belief instead of evidence based on research?
What do we know and how do we know it?
Epistemology is the theory of knowledge, how we know what we know. Medicine is based on ‘evidence based practice’ (EBP) , any suggested intervention should be based on a body of reliable evidence from research.
I’m interested in the questions like:
What should we know?
Where should we get evidence from?
How can we assess whether information is true?
We learn from experience, but how many experiences make something true? If it was true for you, does that mean it will be true for everyone else and in every situation?
Our modern world, from technology, to public health to democracy is based on scientific thinking, the idea that a fact is verifiable, that we can know the world around us by repeated experimentation and therefore make decisions based on evidence.
‘“Facts,” John Adams argued, “are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence.” When facts become opinions, the collective policymaking process of democracy begins to break down. Gone is the common denominator—knowledge—that can bring opposing sides together. Government becomes reactive, expensive and late at solving problems, and the national dialogue becomes mired in warring opinions.’
It is not enough just to find a study that supports a point you want to make, you need to look at the body of evidence, what is the scientific consensus on a topic (because there are always studies that refute the consensus, is that because there really is another truth, or were they badly designed?) the quality of evidence is on a continuum, we cannot just accept the results and conclusions of a study without assessing its quality and design, otherwise we run the risk of promoting misinformation (false or inaccurate information that is spread unintentionally)
What message are we sending when doulas are dismissive of the risks presented by health professionals but openly promote and support practices which have not stood up to scrutiny?
This we can hope at best, causes no harm, but at worst could lead to worse outcomes than if a woman follows the conservative medical approach.
Several commentators on social media provide evidence based commentaries on topics of interest, but these do not always lead to the conclusion we intuitively feel is correct or that we would like to hear, one example is the recent commentary on giving Vitamin K after birth, the author found that:
“Giving a breastfed infant a Vitamin K1 shot virtually eliminates the chance of life-threatening Vitamin K deficiency bleeding. The only known adverse effects of the shot are pain, bleeding, and bruising at the site of the injection”
“Recently, there have been many myths, misconceptions, and misinformation floating around the internet and social media about Vitamin K. It is important that parents look at the facts so that their consent or refusal is informed. Right now, parents who have been declining Vitamin K may not have all the information, or they may have been given inaccurate information.
There was a sense in comments on the article that some people felt disappointed, like the author had let the natural birth world down by agreeing with the position that intervention was better than leaving things alone, but the facts speak for themselves, this was simply a summary of the state of the evidence.
How to assess the quality of research
The type of research to use depends on the research question, but the most reliable type of study is usually considered a randomised controlled trial (which reduces bias) and systematic reviews/meta analysis which summarise and assess the quality of all the available evidence on a particular topic. Qualitative research (based on peoples views and experiences) are seen as increasingly valuable in understanding issues from a holistic perspective.
There are several sites which can help us decide on the quality of a research study.
One useful site which uses a brief questionnaire is DISCERN
The Cochrane collective are well known for producing up to date, reliable evidence summaries, but they also have free training courses on understanding evidence based medicine, assessing research quality and how to search for research
One way to get used to assessing research quality is to join a journal club. I was a member of the NCT journal club before I became a public health researcher and I really enjoyed discussing research methodology and conclusions.
I am considering setting up a Doula UK journal club, to help us explore new research and practice critical appraisal skills, please comment/PM me if you are interested
I feel we need to be mindful about the links we share and the views we put across, , we as doulas should know how to assess the sources we use so that we don’t use unreliable websites or badly designed studies to support our beliefs.
If we ignore scientific consensus (this is not to imply that all discussions with health professionals use up to date and reliable evidence themselves, but that is another blog post entirely) then we risk actively spreading disinformation (intentionally false or inaccurate information, spread deliberately)
This would be a disservice to our community and the women and babies we serve